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Standard Structured Interview
Surveillance of HIV/AIDS Related Events Among Persons Not Receiving Care ("Never In Care")
OMB: 0920-0748
IC ID: 180334
OMB.report
HHS/CDC
OMB 0920-0748
ICR 200906-0920-014
IC 180334
( )
Documents and Forms
Document Name
Document Type
Standard Structured Interview
Form and Instruction
Standard Structured Questionnaire for Never In Care Proj
Attachment 2a Structured Questionnaire.doc
Form and Instruction
Attachment 3 Interview Guide.doc
2007 Interview Guide for Never In Care Project
IC Document
Attachment 5a IC for Structured Interview.doc
Consent Form for Structured Interview
IC Document
Attachment 2c Non-Response Form.doc
Non-Response Data Collection Form
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Standard Structured Interview
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Unchanged
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
None
Standard Structured Questionnaire for Never In Care Project
Attachment 2a Structured Questionnaire.doc
Yes
Yes
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
500
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
500
0
0
0
0
500
Annual IC Time Burden (Hours)
250
0
0
0
0
250
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
2007 Interview Guide for Never In Care Project
Attachment 3 Interview Guide.doc
05/21/2007
Consent Form for Structured Interview
Attachment 5a IC for Structured Interview.doc
05/21/2007
Non-Response Data Collection Form
Attachment 2c Non-Response Form.doc
05/21/2007
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.